The Issue The central issue in this case is whether the Respondent is guilty of the violations alleged in the administrative complaint; and, if so, what penalty should be imposed.
Findings Of Fact Based upon the testimony of the witnesses and the documentary evidence received at the hearing, I make the following findings of fact: The Department is the state agency charged with the responsibility of regulating the profession of nursing pursuant to Chapters 455 and 464, Florida Statutes. At all times material to this case, Respondent has been licensed by the Department, license nos. RN 1672492 and 167249A. Respondent holds dual licensure since he is listed as a registered nurse (RN) and an advanced practice RN with specialty (ARNP). In Respondent's case, the advanced specialty practice is in the area of anesthesia. To become licensed as an ARNP, Respondent submitted an application, a fee, and copies of a certification from the Council on Recertification of Nurse Anesthetists (CRNA) which included an identification card specifying Respondent's CRNA number to be 24936. Respondent represented, under oath, that the copies were true and correct duplicates of the originals. Based upon this documentation, the Department issued the ARNP license. On or about March 25, 1986, Respondent was employed by the Hialeah Anesthesia Group (HAG). Respondent's supervisor was Manuel B. Torres, M. D., president of HAG. On or about November 30, 1987, Dr. Torres notified Respondent that his employment and privileges at Hialeah Hospital were being suspended. According to Dr. Torres, this suspension was to continue until confirmation was given by the Impaired Nurse Program at South Miami Hospital that Respondent's problem had been corrected. At the same time, Dr. Torres notified the CRNA that Respondent had voluntarily entered an impaired nurse program. Subsequently, Dr. Torres received a letter from Susan Caulk, staff secretary for CRNA, which notified him that, according to CRNA files, Respondent had not passed the certification examination, was not a member of the American Association of Nurse Anesthetists, and that Respondent's CRNA recertification number was not valid. Dr. Torres then notified the Department regarding the certification issue. Later, after Respondent had completed a controlled substance addiction program at Mount Sinai Medical Center, Dr. Torres advised him that, if he could prove his CRNA certification, he could be rehired at Hialeah Hospital. Respondent never returned to demonstrate his certification. An individual who represents himself to be certified as an ARNP when he has not qualified to be so certified has exhibited conduct which falls below the standard of care of the nursing practice. Further, such an individual, by practicing as an advanced practitioner without the educational background, compromises the safety of patient care.
The Issue The issue is whether Petitioner meets the academic requirements to sit for the practical nursing equivalency examination in Florida.
Findings Of Fact Petitioner attended the registered nursing program at HCC. On or about March 1, 2007, Petitioner applied to sit for the practical nursing licensure examination. By letter dated May 8, 2008, the Board notified Petitioner that additional information was required to complete her application. According to the letter, two submissions were required. First, the director of nursing at HCC needed to submit a letter stating that Petitioner's coursework meets the practical nursing educational equivalency. Second, Petitioner needed to submit verification that she completed coursework in medical-surgical nursing (oxygenation, circulation and hematology). Rise Sandrowitz, program manager of the nursing program at HCC, submitted a letter to the Board. In the letter dated June 8, 2008, Ms. Sandrowitz stated that while Petitioner was a student at HCC, she "twice attempted but was unsuccessful in Adult Health III." The Adult Health Care III course is a 5.5 credit hour course and covers topics of oxygenation, circulation and hematology. Ms. Sandrowitz' letter does not state that the courses Petitioner completed in the professional nursing program at HCC met the requirements for the practical nursing equivalency. Ms. Sandrowitz testified credibly that the intent of her letter was to recommend that Petitioner be allowed to sit for the examination, if the Board determined that Petitioner's coursework met the practical nursing equivalency requirements. The Board determined that Petitioner's failure to successfully complete the course that covered the oxygenation (respiratory), circulation, and hematology systems demonstrated that she did not meet the practical nursing equivalency requirements. Petitioner testified credibly that each time she took the Adult Health Care III course, she attended "all lectures and every clinical," took every test and quiz, and completed all assignments. Nevertheless, Petitioner did not successfully complete the course. Each time Petitioner took the course, she was "just short of the 80%" needed to pass the lecture part of the course. Despite her failure to pass Adult Health Care III, Petitioner argues that she has adequate knowledge in all nursing areas, including those systems covered in that course and, thus, should be allowed to sit for the practical nursing examination.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered which denies Petitioner, Angela Sessa's, application to sit for the examination for licensure as a practical nurse in Florida. DONE AND ENTERED this 6th day of June, 2008, in Tallahassee, Leon County, Florida. S CAROLYN S. HOLIFIELD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 6th day of June, 2008. COPIES FURNISHED: Lee Ann Gustafson, Esquire Office of the Attorney General The Capitol, Plaza Level 01 Tallahassee, Florida 32399-1050 Angela Sessa 3505 Sandburg Loop Plant City, Florida 33566 Rick Garcia, Executive Director Board of Nursing Department of Health 4052 Bald Cypress Way, Bin C-02 Tallahassee, Florida 32399-1701 Dr. Patricia Dittman, Chairman Board of Nursing Department of Health 4052 Bald Cypress Way, Bin C-02 Tallahassee, Florida 32399-1701 Josefina M. Tamayo, General Counsel Department of Health 4052 Bald Cypress Way, Bin A-02 Tallahassee, Florida 32399-1701 R.S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A-02 Tallahassee, Florida 32399-1701
The Issue Should discipline be imposed by Petitioner against Respondent's license to practice as a licensed practical nurse (L.P.N.)?
Findings Of Fact Findings Established by Request for Admissions: Petitioner is the State of Florida department charged with regulating the practice of nursing pursuant to Section 20.43, Florida Statutes, Chapter 456, Florida Statutes, and Chapter 464, Florida Statutes. Respondent is and has been at all time material to the complaint a L.P.N. in the State of Florida, having been issued license number 9246217. Respondent's address of record is Post Office Box 99, High Springs, Florida 32655-0099. At all times material to this case, Respondent was employed as a L.P.N. by Suwannee Home Care and Medical Personnel, a staffing agency. At all times material to this case, Respondent was assigned to work as a L.P.N. at Alachua Nursing and Rehabilitation in Gainesville, Florida (Alachua). At all times material to this case, Alachua in Gainesville, was a licensed rehabilitation facility as defined in Section 400.021(13), Florida Statutes. At all times material to this case, Patient E.D. was admitted to Alachua (having been admitted) on June 20, 2003, with a diagnosis of status post CVA (stroke). On or about June 21, 2003, Respondent was assigned to care for E.D. on the 3 to 11 p.m. shift, and at the end of the shift, Respondent reported to the oncoming nurse that he assisted with the care of E.D. and that E.D. was okay and in no acute distress. Respondent's nurse's notes regarding the care he provided to patient E.D. do not mention whether he suctioned the tracheostomy care being provided; and do not contain any physical assessment of the patient. Respondent should have performed and documented tracheostomy care, including but not limited to frequency of suctioning, amount of color of sputum suctioned, cleaning of the tracheostomy device, oral hygiene, and method of communication with the patient. Respondent should have performed and documented a physical assessment of the patient that included respiratory rate and effort, color, pulse rate, and exertional level. Respondent should have monitored and followed up on patient E.D.'s vital signs. Additional Facts: Alice Bostick, is a Medical Malpractice Investigator for Petitioner. She was involved in the investigation leading to the drafting of the Administrative Complaint. As part of the process she attempted to notify Respondent of the allegations made against him. On July 15, 2003, she sent a letter of notification to Respondent at an address obtained from a printout of license information associated with Respondent. That address was 13134 North 22nd Street, Apartment 109, Tampa, Florida 33612. The information sent to Respondent was a Uniform Complaint Form and a Nursing Home Adverse Incident Report. The information sent to Respondent was returned as undeliverable and not subject to forwarding, absent a forwarding request made from Respondent to the U.S. Postal Service. Having failed to notify Respondent at the Tampa address, Ms. Bostick took advantage of access which the Petitioner has to the Florida Department of Highway Safety and Motor Vehicles records to locate Respondent's address maintained by the other state agency. The address provided by the other agency was Post Office Box 99, High Springs, Florida 32655-0099. This was the proper address. Utilizing the new address, the same information was dispatched a second time from Petitioner to Respondent. This time it was not returned as undelivered. Instead Respondent contacted Petitioner's office in person and by his remarks made it known that he received the communication from Petitioner concerning the investigation. At times relevant to this case Respondent worked for the Suwannee Valley Nursing Agency. That agency assigned him to work on a shift at Alachua, now the Manor of Gainesville. On June 21, 2003, Respondent worked the 3:00 p.m., to 11:00 p.m., shift at Alachua. One of the resident's in his care at that time was E.D. Resident E.D. was born on May 18, 1920. She had been released from the hospital on June 20, 2003, and transferred to Alachua. She was receiving oxygen. Physician's orders called for tracheostomy care (trach care) to be administered "Q 6 hours." She had a catheter which was last changed on the date of her release from the hospital. The order indicated that the catheter should be changed every Friday beyond that point. The resident was being fed by tube. As Respondent describes it, E.D. was among 30 patients in his care on the shift. Other residents included persons with G-tubes and insulin-dependent diabetics. Respondent was very busy during his shift helping the residents. Another staff member at the nursing home reminded the Respondent that he needed to suction E.D's trach. At some point in time Respondent and the other staff member suctioned the trach. When this function was performed during the shift is not established in the nursing home record pertaining to resident E.D., as that record was presented at the hearing. Therefore it was not shown an entry was made in the resident's record for care confirming the suctioning of the trach. The only reference to patient E.D. made in writing by Respondent presented at hearing, was from nursing notes related to resident E.D. In the nurse's note Respondent made an entry at the end of his shift as to vital signs for the resident, pulse rate 92, respiration rate 24 and a notation that Respondent "Assisted e-care no acute distress noted." Contrary to the nurse's note made by Respondent, resident E.D. was in distress as discovered by Gloria Brown, L.P.N., who came on shift to work from 11:00 p.m. June 21, 2003, until 7:00 a.m. June 22, 2003. Ms. Brown was familiar with the need to suction a trach and to make appropriate entry in the nursing notes in caring for a trach patient. Notes are also made in relation to oxygen saturation for that resident if a doctor's order calls for that entry. Ms. Brown properly expected the prior shift nurse to notify her concerning the resident's condition as to the number of liters of O2 provided the resident and if the resident had a fever. If the resident had a Foley catheter placed reference would be made to that circumstance. Generally if the resident was experiencing a problem, Ms. Brown would expect the outgoing nurse to mention that fact. On June 21, 2003, at 11:45 p.m., as Ms. Brown described in the nursing notes, "On first rounds observed resident E.D. with shallow breathing, skin color grayish, O2 on a 2 liter per trach mask. Attempt to suction, felt resistance. Sat. 24. O2 increased to three liters. Able to palpate pulse. 911 was called. Transported to Shands at UF via 911. Respiratory distress." Resident E.D. was transported to Shands Hospital at 12:00 midnight. When resident E.D. was transported to the hospital she was experiencing respiratory distress. She had a baseline level of consciousness in the alert range. Petitioner presented an expert to comment on Respondent's care rendered resident E.D. in the context of the allegations set forth in the Administrative Complaint. That expert was Meiko D. Mills, R.N., M.N.S., A.R.N.P. Ms. Mills is licensed to practice nursing in Florida. She has a business that involves the preparation for graduates of L.P.N. schools and R.N. schools to take the National Licensing Examination for those fields. Ms. Mills is familiar with trach care. She has had occasion to write nursing notes pertaining to trach care. She is generally familiar with the requirements for nursing notes in the patient record concerning any form of patient care rendered by the nurse practitioner. She was recognized in this case as an expert in the field of nursing related to patient care and L.P.N.s. In providing trach care, Ms. Mills refers to the need for a sterile environment and the part of the trach device that she refers to as a tube, requires a lot of cleaning because of secretions from the patient. She describes the fact that the trach device will form a crust. As a result the center portion of the device sometimes has to be taken out and soaked in sterile water to clean it. The suctioning process associated with trach care involves the use of a suctioning machine in which all the encrustations and saliva are removed. It is possible for a hard mucus plug to form if suctioning is not done appropriately, according to Ms. Mills. Ms. Mills expressed her opinion concerning Respondent's care provided resident E.D., as to a reasonable degree of certainty and whether Respondent met the minimal standards for acceptable and prevailing care and treatment of E.D. She described that care as lacking. Ms. Mills comments that the nursing note that was made by Respondent at the end of his shift was inadequate in describing the kind of care provided to the resident. In particular she describes the lack of reference to the trach issue and the oxygen saturation issue. She perceives that E.D. required considerable attention and that attention is not reflected in the nursing note. As a person responsible for providing care to E.D., who had a trach, Ms. Mills refers to the need for the Respondent to establish a baseline at the beginning of the shift. That baseline is constituted of vital signs and oxygen saturation, as well as a basic assessment of the resident. There was the need to compare the vital signs assessment to the shift before Respondent came on duty to gain an impression of any trends. The observations by Respondent should have been documented in nursing notes beginning with the baseline as to vital signs, oxygen saturation, reference to the condition of the trach, respiratory effort and so forth, and there was the need to go back and reassess over time. As Ms. Mills explains the resident's condition was reaching an abnormal state on the shift before. Without entries concerning the resident's condition, the assumption is made by Ms. Mills, that the patient care and in particular trach care was not performed by Respondent. Ms. Mills refers to a normal pulse rate as 80 to 100, but Ms. Mills cautions her students that a pulse rate close to 100 bears watching. A respiration rate approaching the highest normal demands attention. Anything above that creates concern. Higher readings tend to manifest themselves with shallower breathing by patient at more frequent intervals, given the body's attempt to compensate for a lack of oxygen. To address this condition a baseline oxygen saturation should be established at the beginning of a shift to help set a plan of care. A resident such as E.D. with a pulse rate of 97 and respiration rate of 24 is a person who needs to be closely monitored. There was no record by Respondent reflecting the establishment of monitoring to address these circumstances. The resident's progress should have been noted as to pulse rate and respiration rate several times during Respondent's shift, as Ms. Mills perceives it. Respondent should have also notified the oncoming nurse for the following shift that the patient was not doing well. This was not done. Overall, Ms. Mills feels that Respondent was deficient in his documentation concerning resident E.D. through the nursing notes. The general comment by Respondent that he assisted with care is not sufficient to establish that trach care was performed in Ms. Mills opinion. According to Ms. Mills, some of the vital signs reflected in the resident's record would create the possibility that they were in relation to a mucus plug in the trach. When the Resident E.D. was transported from the nursing home on June 21, 2003, at 11:30 the oxygen saturation at that time was 78 percent and her pulse was 159. In Ms. Mills opinion those values represented the fact that the resident was in distress. Ms. Mills believes that Respondent engaged in unprofessional conduct by acts of omission. Ms. Mills compared the nursing notes made by Respondent to those made by nurses on the prior two shifts at the nursing home. The prior notes were described as good notes talking about the care, while Ms. Mills did not get the same feeling about the notes made by Respondent. Ms. Mills compared the circumstances when Respondent came on shift when resident E.D. had a pulse of 100 and respiration rate of 20 and the change from the respiration of 20 to the respiration rate of 24 at the end of the shift, as indicating that the resident had shallow compensatory respiration because of a lack of oxygen. This leads Ms. Mills to the conclusion that the vital signs look worse and the person was significantly compromised over the day. Whether this circumstance was brought about by the formation of a plug due to a lack of trach care, Ms. Mills is not certain, but the vital signs indicate that the resident was sufficiently compromised to alert a health professional to that possibility. Earlier in the day the resident had a respiration rate of 28 and a pulse of 110. The change in those values over time up through the Respondent's shift did not indicate improvement in resident's condition in Ms. Mills' opinion. Ms. Mills' opinions that have been described are accepted. Based upon the facts found and Ms. Mills' expert opinion, Respondent failed to meet minimal standards of acceptable and prevailing nursing practice in the care provided resident E.D.
Recommendation Upon consideration of the facts found and the conclusions of law reached, it is RECOMMENDED: That a final order be entered finding Respondent in violation of those provisions of law set forth in Counts One through Three, calling for a written reprimand for those violations, imposing an administrative fine of $500.00, and placing Respondent on probation for a period of two years. DONE AND ENTERED this 24th day of May, 2005, in Tallahassee, Leon County, Florida. S CHARLES C. ADAMS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 24th day of May, 2005. COPIES FURNISHED: Judith A. Law, Esquire J. Blake Hunter, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Harvey J. Price Post Office Box 99 High Springs, Florida 32655 Dan Coble, Executive Director Board of Nursing Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
Findings Of Fact At all times pertinent to the issues herein, Respondent, Thelma L. Jones, was licensed as a Licensed Practical Nurse in Florida, holding license number PN 0704471, and Petitioner was the agency responsible for licensing nurses in Florida. On June 2, 1986, Respondent was employed as a LPN by the Glades Health Care Center in Pahokee, Florida, as nurse on the 3-11 p.m. shift. She was assigned to the West Wing of the facility, and was assisted by at least two nursing assistants. Kathy Davis, another LPN, was assigned to the East Wing of the facility with her assistants, and in that location, though not officially identified as such, was the charge nurse for the entire facility. Though licensed as a 120 bed skilled nursing home, GHCC somewhat resembles an acute care facility, since the least seriously ill patient is normally more severely affected than those in most nursing homes. The patient census at that facility at the time was between 45-60 patients, total, in both wings. The facility is a one-story building with the two parallel nursing wings separated by a corridor. While possible, it would be extremely difficult for one nurse to service both wings. At approximately 3:50 p.m., on June 2, 1986, Respondent clocked in for work at the facility, approximately 50 minutes late. She immediately went to the West Wing, where she told Ms. Davis she was quitting and delivered to her the letter of resignation she had prepared that same day. Ms. Jones then returned to her duty station and attempted to contact the Director of Nursing, Mr. Gooley by phone, but was unable to do so. She then went out on the floor and spoke with some of the patients with whom she was most friendly, telling them she was leaving, but assuring them they would be taken care of. She returned to her station and again tried to contact Mr. Gooley by phone without success. After passing out some medications and making the required entries on some medical records, and after making a count of the narcotics as required, but without making an official record of it, she went back to Ms. Davis and told her she could not reach Mr. Gooley. Ms. Jones states that Ms. Davis replied, "Don't worry about it. I'll call him." After going back to the West Wing to collect her belongings, Ms. Jones then went to the front exit, where, over the television security monitor, she again spoke to Ms. Davis, who, for the second time, allegedly said she'd call Mr. Gooley. At this point, Ms. Jones saw a wandering resident trying to run away from the facility. She caught him and turned him over to a nursing assistant and for the third time, called Ms. Davis, who advised her she had reached Mr. Gooley and he was on his way in. Ms. Davis reportedly told Ms. Jones there was no reason she should stay. According to her time clock records, Ms. Jones punched out at approximately 5:40 p.m. She contends, however, she did not leave immediately, but stayed at least an hour after punching out. Mr. Gooley, on the other hand, indicated he arrived at the facility, pursuant to Ms. Davis' call, at approximately 5:50, and though he walked through the whole facility, failed to see Ms. Jones. It is found, therefore, that Ms. Jones left prior to the arrival of Mr. Gooley. After his walk through the facility, Mr. Gooley asked Ms. Davis where Respondent was, at which point, Ms. Davis handed him Respondent's letter of resignation and the key to the narcotics cart on the East Wing. Mr. Gooley immediately went to that wing, where he counted the narcotics with Ms. Davis present. He checked other records and determined that certain medications due to be dispensed at 5:00 p.m. by the Respondent, had apparently not been dispensed. Ms. Jones strongly contends that no patient due medicines failed to receive them prior to her departure and that she noted this in at least one record in each file. She admits, however, and it is so found, that she did not complete all records necessary prior to her departure. To ensure the East Wing was properly covered after Respondent's departure, Mr. Gooley remained on duty until relieved at the 11:00 p.m. shift change. Ms. Jones asserts her departure was justified and was not without authority. She had had some previous discussion with Mr. Gooley about the proposed change in working hours to require 12 hour, 8:00 a.m. to 8:00 p.m., shifts. Since her husband went to work at 4:00 a.m. and she had two children to care for, she advised him she could not work those hours. He insisted that she do so, however. On the day before she left, when she came to work, she again spoke with Mr. Gooley about the problem and he is reported to have advised her that her family was of no importance to him and she had to work the new hours. Mr. Gooley denies this. That same day, Respondent's husband told her he was being transferred to Leesburg and she could go up there with him to work. Whether or not the aforementioned colloquy took place is immaterial. Investigation by DPR reveals Ms. Jones did not leave Clewiston right away after she left her position with GHCC, but remained in town for several days. She returned to Clewiston after staying in Leesburg for only a week or so. When hired, each employee of GHCC is given a handbook which contains the facility's policy on resignation. This policy calls for two weeks notice to be given, in the case of nurses, to the Director of Nursing. Ms. Jones failed to give two weeks notice either orally or in writing. Respondent also contends that since Ms. Davis was the nurse in charge, she had authority to release Ms. Jones when Ms. Jones decided to quit. Mr. Gooley contends, and his contention is well taken, that though the East Wing nurse held the more senior position of the two, and had authority to answer the phone, call for fire support, and perform other routine tasks, her authority did not include receiving and approving letters of resignation. Ms. Jones also contends that by notifying Ms. Davis of her intent to leave at least an hour before delivering the letter of resignation, she gave ample notice. She asserts that because the State's staffing rules were not violated by her departure, and because Ms. Davis had her own aides as well as Respondent's after she left, no harm was done by her leaving. She had previously handled the whole facility by herself with only aides, even to the extent of passing medications. When she left, though it was during a shift, she was satisfied that everything that needed to be done was done and that Ms. Davis could handle anything that came up. Mr. Gooley, on the other hand, is of the opinion that her leaving without authority; her departure without dispensing medications; and her failure to sign off on the narcotics register, itself a violation, is not consistent with the fundamental standards of proper nursing practice in Florida. Though one nurse, plus aides, may meet the State staffing requirements, in his opinion, one nurse cannot, in light of the physical layout of this facility, handle all patients in both wings. To leave only one licensed nurse in charge of the whole facility could endanger the patients. For the past two years or so, Respondent has served as the nurse in charge of the medical facility at the Palm Beach County Jail, where she has been observed on a daily basis by Lieutenant William Arthur, under whose administrative supervision she falls. He is most pleased with her work and believes that due to her efforts, the facility has received clean inspection reports since she began working there. This is unusual for jail medical facilities. He has found her to be very conscientious in her work, and an employee who anticipates problems, solving them before they grow out of hand.
Findings Of Fact Respondent, Ann Claycomb (Claycomb), was at all times material hereto a licensed practical nurse in the State of Florida, having been issued license number 39853-1. On December 24, 1987, Claycomb was employed as an agency nurse by Alpha Health Care, Inc., and was on assignment to Health South Rehabilitation, a skilled nursing and rehabilitation facility in Miami, Florida. While at the facility on that date, Claycomb worked the morning shift 7:00 a.m. to 3:30 p.m., and was assigned to the skilled nursing floor. The skilled nursing floor contained 20-25 elderly, though mostly alert patients. At the commencement of Claycomb's shift, it was her responsibility to administer medications to these patients which conformed with that prescribed by their medication administration record (MAR). Shortly after Claycomb began her rounds, Elaine Wood, the Unit Manager at Health South Rehabilitation, began to receive complaints from patients for what they perceived to be errors in the medicinal drugs administered or attempted to be administered to them by Claycomb. Upon investigation, the following medication errors were discovered. Claycomb administered what she believed to be two Tylenol tablets to patient H.B. Following administration, the patient became lethargic and her vital signs deteriorated but later returned to normal. Lethargy is not a side effect of Tylenol. Although the MAR prescribed two Slow K tablets at 9:00 a.m., and Lilbrax as needed, Claycomb recorded having administered one Slow K tablet and Atarax to patient H.R. Claycomb dispensed Atarax to patient A.J. at 9:00 a.m. when the MAR prescribed dose to be given at 1:00 p.m. Patient refused medication because given at the wrong time. In committing the foregoing medication errors Claycomb's practice fell below the minimal standards of acceptable and prevailing nursing practice in the administration of medicinal drugs. Verification of other complaints received by Ms. Wood could not be verified because, contrary to accepted and prevailing nursing practice, Claycomb did not annotate some patients' MAR upon dispensing medications.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that a final order be entered suspending the license of respondent, Ann Claycomb, until such time as she submits proof satisfactory to the Board of Nursing that she can practice nursing safely. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 27th day of December, 1988. WILLIAM J. KENDRICK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 27th day of December, 1988. APPENDIX TO RECOMMENDED ORDER, CASE NO. 88-3603 Petitioner's proposed findings of fact are addressed as follows: 1. Addressed in paragraph 1. 2-4. Addressed in paragraphs 2 and 3. 5 & 6. Addressed in paragraphs 46. Addressed in paragraph 4c. Subordinate or not necessary to result reached. Not necessary to result reached. Not necessary to result reached. To the extent supported by competent proof addressed in paragraph 4. Proposed findings 11a and 11d are based on hearsay which does not supplement or explain any competent proof. 12-15. Not pertinent nor necessary to result reached. COPIES FURNISHED: Michael A. Mone', Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Ms. Ann Claycomb 4175 South West 98th Avenue Miami, Florida 33165 Lawrence M. Shoot, Esquire 6011 West 16th Avenue Hialeah, Florida 33012 Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32201 Bruce D. Lamb, Esquire General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
Findings Of Fact During early 1982, Petitioner submitted an application for licensure as an Advanced Registered Nurse Practitioner in the category of Midwifery. Petitioner's application was reviewed by the Respondent, Board of Nursing, on July 21, 1982. By letter of that date, Petitioner was advised that her application for certification as an Advanced Registered Nurse Practitioner did not meet the criteria for certification as set forth and defined in Section 464.012(1), Florida Statutes. Specifically, Petitioner was advised that: The midwifery training that she completed in 1962 in England was note post-basic. Enrollment as a midwife on the Central Midwife's Board has not been recognized as an "an appropriate" specialty board for certifi- cation as an Advanced Registered Nurse Practitioner, and The master's degree preparation that Petitioner acquired is not from a program leading to a master's degree in a nursing clinical specialty area. (Petitioner holds a master's degree in Education) Petitioner was further advised that she had one other means of being certified. I.e., that "registered nurses who have received their midwifery training outside the United States may be certified if they have completed an American college of nurse midwifery approved refresher program and the registered nurse is deemed eligible to take the ACNM examination. [Rule 210-11.23(2)(c), Florida Administrative Code] (Petitioner's Exhibits 2 and 3) Petitioner is a currently licensed registered nurse in the State of Florida, having been issued license number 30882-2, on January 1, 1964, by examination. Further, Petitioner was admitted to the Central Midwives' Board (London, England) after successfully completing a one year course of training undertaken by pupils who had previously qualified as state- registered general trained nurses. Petitioner took a three years' course of general nurse training at Bedford General Hospital from 1957 through 1960 and commenced midwifery training on August 1, 1961, as confirmed in the verification of her training and enrollment as a midwife. Debra Fitzgerald, a resident of Atlanta, Georgia, on May 26, 1983, was previously employed by the Respondent, Board of Nursing, from July, 1980 to February, 1983, as a nursing consultant in the educational section dealing primarily with the certification of applicants in the field of ARNP. As part of her duties as an employee of the Respondent, Ms. Fitzgerald reviewed the application of the Petitioner for certification as an ARNP. Upon review of the Petitioner's application, it is determined that the program that the Petitioner attended in midwifery during 1961-1962 in England was not a formal post-basic program equivalent to the standards required of formal post-basic programs in this country. Rule 21D-11.24, Florida Administrative Code. Petitioner was given credit for a total of one hundred four (104) didactic hours and the Board requires a minimum of one hundred twenty (120) didactic hours for proof of the equivalent of a post-basic course requirement in obstetrical nursing. (Testimony of Fitzgerald [by deposition]) Petitioner has not otherwise satisfied the criteria to be certified in keening with Rule 21D-11.23(2)(c)1 or 2, Florida Administrative Code.
Findings Of Fact Petitioner became a Registered Nurse in 1965 and has been engaged in the nursing profession since that time. She was awarded a Bachelor of Science in nursing in 1975 from Florida International University and is presently enrolled in the masters of nursing degree program at the University of Miami. In 1973 Petitioner enrolled in the Primary Care Nurse Practitioner program at the University of Miami and successfully completed the six months program in December 1973. During this program she received 1,000 hours training. Upon completion of this training, Petitioner was eligible for licensure as an Advanced Nurse Practitioner but did not apply for registration at that time although she worked as a Nurse Practitioner immediately upon completion of the training. From January 1974 to March 1977 Petitioner worked at Jackson Memorial Hospital at Miami as an Advanced Family Nurse Practitioner. During this period she received actual instruction of approximately one hour per day for a total of some 710 hours in duties of Nurse Practitioner in addition to the daily experience gained working as a Nurse Practitioner. In 1977 Petitioner moved to Colorado where she worked as a Nurse Practitioner from October 1977 until April 1978 for the Rocky Mountain Planned Parenthood organization and the Mountain Community Medical Clinic. In the latter position she manned a clinic that was some 30 to 40 miles from the nearest doctor and communicated with the doctor by telephone in diagnosing and treating patients. She worked some 348 hours in this position. Additionally, Petitioner taught in the Nurse Practitioner program at the University of Colorado one to three days per week from January until May 1978. Upon Petitioner's return to Florida in May 1978 she applied for licensure as an Advanced Nurse Practitioner and was denied licensure because the regulations were changed effective March 31, 1978, to require a one-year educational training program in lieu of the six months program completed by Petitioner. The current approved program at the University of Miami provides some 1,105 hours of training similar to the training Petitioner obtained at the earlier course.
The Issue The issues are whether Respondent violated Section 464.018(1)(h), Florida Statutes, and Rules 64B9-8.005(2) and 64B9-8.005(12), Florida Administrative Code, and if so, what penalty should be imposed.
Findings Of Fact Petitioner is the agency charged with the regulatory and prosecutorial duties related to nursing practice in Florida. Respondent is a licensed practical nurse in Florida, holding license no. PN 0481631. From May 13, 1992, to April 11, 1997, she was employed by Southlake Nursing and Rehabilitation Center (Southlake). On April 9, 1997, Respondent worked as a nurse on the 3:00 p.m. to 11:00 p.m. shift on Southlake's A wing. T.C. was a patient of another nurse on that wing. Around 7:00 p.m., Respondent began administering medications to her patients. Melody Perez, the ward clerk, informed Respondent that T.C. needed assistance because he was in respiratory distress. T.C. was sitting in the hall, six to eight feet from Respondent. Respondent went over to T.C., checked to make sure that there was oxygen in his tank and that his nasal cannula was in place. Respondent saw no outward symptoms of T.C. being in acute respiratory distress such as rapid breathing or anxiety. Respondent told Ms. Perez that she could not help T.C. because he was not her patient. She told T.C. that his nurse, who was on break and had the keys to the other medication cart, would be back in a few minutes. Respondent thought that T.C. just wanted his medications. She did not perform a nursing assessment, as that term is commonly understood in the practice of nursing. She did not take T.C.'s vital signs, count his respirations, or listen to his chest. After telling him to wait for his nurse, she just walked away. On April 10, 1997, T.C. and another resident complained to Southlake's administrative staff about Respondent's failure to help T.C. Southlake initiated an investigation based on these complaints. Conchita Griffin, Southlake's Assistant Director of Nursing, conducted the investigation. As was the custom and procedure at Southlake, Ms. Griffin interviewed T.C., the second complaining resident, Ms. Perez, and two certified nursing assistants (CNAs) who were on duty during the incident. Ms. Griffin then compiled a written report of the incident and submitted it to Southlake's administration. Based on her investigation, and after considering Respondent's disciplinary history at Southlake, Ms. Griffin recommended that Southlake terminate Respondent. Southlake had written policies requiring a nurse to attend to any resident who needed help. The policies require a nurse to assess a patient complaining of respiratory distress by taking the patient's vital signs, listening to respirations and to the chest for congestion. According to the policies, a nurse should attend to any patient in distress, calling the patient's assigned nurse, facility management, or 911 if needed. There are no circumstances where the nurse should do nothing. On April 11, 1997, Respondent was called in and asked about her side of the incident. She admitted that she looked at T.C. and that he did not appear to be in distress. She acknowledged that she did nothing except tell T.C. that his nurse would be back soon. When informed that she was being terminated, Respondent refused to sign the disciplinary form. She was asked to leave the premises immediately. Sharon Wards-Brown, Southlake's nursing supervisor for the evening shift in question, accompanied Respondent to A wing to retrieve her belongings. When Respondent arrived on the A wing, she went into the medication room, picked up T.C.'s chart, removed some pages from the chart, and went to the fax machine just outside the medication room. Ms. Wards-Brown and Beverly Burstell, the nurse manager who was on the floor checking some charts, saw Respondent remove the pages from T.C.'s chart and go to the fax machine. Both of them told Respondent that she could not remove or copy anything from the resident's chart. Respondent told Ms. Wards-Brown and Ms. Burstell not to touch her. Each page of nurses' notes in the patients' charts have a front and back side. Respondent stood at the fax machine for only a couple of seconds, not long enough to copy both sides of one page of nurses' notes. She certainly did not have time to copy both sides of all of the pages that she had removed from T.C.'s chart. Respondent's testimony that she had time to copy some of the nurses' notes from T.C.'s chart is not persuasive. Her testimony that she left all of the original pages in the fax machine is not credible. After being prevented from copying all of the pages that she had removed from T.C.'s chart, Respondent ran into the bathroom. A few seconds later she came out of the bathroom with papers and her purse in her hand. Ms. Wards-Brown called Clara Corcoran, Southlake's administrator, and Ms. Griffen for assistance. All three of them followed Respondent out of the building, demanding that she return the documents that she had removed from T.C.'s chart. Respondent repeatedly told them not to touch her. Ms. Corcoran and Ms. Griffen followed Respondent into the parking lot. Respondent got in her car but Ms. Corcoran and Ms. Griffen blocked Respondent from closing the car door and continued to demand the return of the papers. Respondent finally drove forward over the cement bumper and the grass in order to leave with the papers. Meanwhile, Ms. Wards-Brown returned to the A wing to examine T.C.'s chart. Ms. Griffen also examined the chart within two to three minutes after Respondent left the floor. The chart was still open on the desk. Ms. Wards-Brown and Ms. Griffen discovered that T.C.'s nurses' notes for April 9, 1997, were missing. They knew the notes were missing because both of them had seen the notes in the chart the day before when they reviewed the chart as part of the investigation. Respondent's Exhibit 2 is a copy of the front and back of one page of T.C.'s nurses' notes. The last note is dated March 27, 1997. It is not plausible that T.C.'s chart had no nurses' notes from that time until after April 10, 1997. Even if Respondent did not remove any of T.C.'s original nurses' notes from the premises, she violated the acceptable standards of nursing care by copying the front and back of one page and removing the copies from the facility.
Recommendation Based on the foregoing Findings of Facts and Conclusions of Law, it is RECOMMENDED: That Petitioner enter a final order fining Respondent $1,000 and suspending her license for one year, followed by two years of probation with appropriate conditions. DONE AND ENTERED this 10th day of October, 2000, in Tallahassee, Leon County, Florida. SUZANNE F. HOOD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 10th day of October, 2000. COPIES FURNISHED: Diane K. Kiesling, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Room 3231A Tallahassee, Florida 32308 Thomas A. Delegal, III, Esquire Randy Rogers, Esquire Delegal & Merritt, P.A. 424 East Monroe Street Jacksonville, Florida 32202-2837 Ruth R. Stiehl, Ph.D., R.N. Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4042 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue The issue in the case is whether the allegations set forth in the Administrative Complaint filed against the Respondent are correct and, if so, what penalty should be imposed.
Findings Of Fact The Petitioner is the state agency charged with the responsibility for regulation and discipline of nursing practice within the State of Florida. The Respondent is a registered nurse holding Florida license number 2551692. On June 1, 2000, the Respondent was employed as a registered nurse at Harborside Healthcare Nursing Home. The Respondent was assigned to provide patient care including administration of medications to residents. L. M. was a resident of Harborside Healthcare. L. M. was a diabetic and required insulin injection as a part of her treatment for the diabetes. On June 1, 2000, the Respondent attempted to administer an insulin injection to L. M. Two Certified Nursing Assistants were present in L. M.'s room at the time of the injection. When the Respondent began the injection, L. M. "jumped" or "jerked," and the Respondent struck L. M.'s arm with the Respondent's closed fist. Both of the nursing assistants reported the incident to the facility's Director of Nursing. The Director of Nursing investigated the incident and discussed it with the Respondent, who initially admitted the striking although she later denied the event. The Respondent was immediately suspended from her employment and was subsequently terminated. Minimal standards of professional nursing practice prohibit the striking of a patient.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department of Health, Board of Nursing, enter a Final Order imposing an administrative fine of $1,000, and suspending the Respondent's licensure until such time as the Respondent provides to the Board proof of her ability to practice nursing safely, after which the Respondent shall be placed on probation for a one-year period under such conditions as the Board deems appropriate. DONE AND ENTERED this 27th day of August, 2001, in Tallahassee, Leon County, Florida. WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 27th day of August, 2001. COPIES FURNISHED: Beverly Cooper 2801 Belle Chase Circle Tampa, Florida 33634 Michael J. Kapperman, Esquire Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Ruth R. Stiehl, Ph.D., R.N., Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714
